Mini-laparoscopic surgery refers to surgery performed with laparoscopes and instruments of less than 3 mm, also known as mini-laparoscopic surgery, which develops on the basis of traditional laparoscopic surgery and further minimizes the invasiveness of laparoscopic surgery. In 1996, China started to apply 2mm laparoscopic surgical instruments to perform minilaparoscopic cholecystectomy (MLC) for some patients with gallbladder disease, which was called needle-type laparoscopic cholecystectomy at that time. The MLC has undergone several improvements over the past decade, and today’s MLC technique is more rational and refined. The modified MLC [4] has become a routine procedure in many hospitals. The characteristics of our MLC are: (1) It is operated with instruments less than 3 mm, the wound is subtle, the surgical scar is completely invisible or almost invisible for several months after surgery, and the cosmetic effect is good. (2) No clamps are applied during the operation, and the operation is delicate, with no or very little bleeding. (3) The blood vessels and gallbladder ducts are all ligated with wires, and no metal foreign body is left in the abdominal cavity. It is widely welcomed for its cosmetic and postoperative comprehensive effect. Liu Yanmin, Department of Minimally Invasive General Surgery, The First Hospital of Guangzhou Medical University
1 Indications for MLC
Gallbladder polyps with wall thickness <4mm and gallbladder stones without acute inflammation and chronic cholecystitis with non-stones but obvious symptoms.
2 Methods
2.1 Instruments Mini-laparoscopic surgical instruments include mini grasping forceps, separating forceps, scissors, hook electrodes and matching puncture cannulae with diameters of 1.7 mm, 2 mm, 2.5 mm, 2.8 mm and 3 mm. The laparoscope is also available in 1.7 mm, 3 mm, 4 mm, and 5 mm diameters, and MLCs are mainly selected in 2 mm, 2.5 mm, 2.8 mm, and 3 mm diameters. Modified MLCs are available with 5mm diameter instruments and 10mm laparoscopes. A 10mm operating scope with an operating orifice has also been used.
2.2 Surgical methods
2.2.1 Laparoscopic approach Because the gallbladder specimen requires a slightly larger outlet, and one of the goals of minisurgery is cosmetic, both domestic and foreign colleagues have located this outlet in the more concealed umbilical fossa. In this way, the umbilical fossa wound serves both as an exit for the gallbladder specimen and as a 10 mm laparoscopic access.
2.2.2 Operation holes The upper abdominal entrance has a three-hole method with operation channel diameters of 2 mm and 5 mm, respectively. four-hole method with operation channels of 2 mm, 2 mm, 5 mm or 2 mm, 2 mm and 2~3 mm, respectively. four-hole method is mostly used in our hospital, and all instruments below 3 mm are selected for high cosmetic requirements. some doctors also use 5 mm trocar and instruments at the subxiphoid entrance to facilitate the entry and exit of the applicator and shorten the operation The two-hole method uses a device with an operating channel. The two-hole method uses a laparoscope with an operating channel, in which the channel can be exposed with the help of a clamp, and only a 5-mm incision is made in the upper abdomen to place a puncture trocar as the main operating channel. The “two-hole method” is also used for those who do not have this operating scope, where a suture is threaded through the base of the gallbladder and pulled out of the abdominal cavity to aid exposure.
2.2.3 Separation If the main operating hole is 5 mm below the glabella, traditional LC surgical instruments and methods can be used for separation. If all instruments below 3 mm are used, hook electrodes and separating forceps are commonly used tools, among which separating forceps are more effective in separating and stopping hemorrhage.
2.2.4 Gallbladder duct and gallbladder artery treatment If the subscapular approach is done with a 5mm trocar, the artery and gallbladder duct can be treated with optional 5mm sizer, or ligated with silk and ligature wire. If all the instruments below 3 mm in diameter are used, the operator must carefully separate and dissect them to avoid bleeding, and the gallbladder artery and duct can be ligated with a wire. The gallbladder artery can also be treated by electrocoagulation with separating forceps.
2.2.5 Gallbladder specimen processing In the early days, a 3-mm microscope was used to monitor from the subxiphoid entrance, and the instruments entered the abdominal cavity through the umbilical cannula to grasp the gallbladder specimen for removal. abdominal cavity. If there is no specimen bag, a 40-50 cm-long No. 7 wire can be used to send one end of the wire into the abdominal cavity through the umbilical cannula after the separation of the cystic duct is completed, and the distal end of the cystic duct is ligated with the wire, while the other end of the wire remains outside the umbilical cannula. After the gallbladder is removed from the gallbladder bed, the tail of the thread outside the mouth of the umbilical trocar is pulled while retracting the scope to pull the gallbladder specimen into the umbilical trocar, and then the specimen is pulled out together with the trocar.
3 Surgical results of MLC
Most of the cases requesting MLC were evaluated preoperatively and selected according to the indications; the gallbladder was free of acute inflammation, the anatomical level was clear, and the surgical separation was easy; because of the fine instruments and more careful operation by the surgeon, there was no bleeding or less than 5 ml of bleeding in most cases. the incidence of intraoperative change of operation and conversion to conventional laparoscopic surgery or open operation was reported in the literature as 1-10%, and the reasons for conversion were bleeding from ruptured gallbladder artery, inflammation of the gallbladder, tight adhesions, intestinal injury, gallbladder rupture and bile duct injury. In our hospital, there were more than 2540 cases of MLC in more than 10 years, and about 1% of them were converted to conventional laparoscopy, mainly because of cholecystitis, thick gallbladder wall, difficulty of micro-gripping clamp, tight surrounding adhesions and intraoperative instrument damage. No significant complications were seen. The umbilical wound was the outlet of the gallbladder specimen, and in early cases the specimen was pulled out directly from the wound without entering the bag. All were non-surgical cures. Later we switched to gallbladder bags and contamination was significantly reduced, with an umbilical wound infection rate of 1.4%. Comparative studies have demonstrated that MLC is less painful after surgery , and all patients were out of bed and eating the next day after surgery. The duration of hospitalization was 24 hours abroad and 3 days in China. The upper abdominal wound heals fastest, and most mini-incision scars disappear after 3-6 months postoperatively. The umbilical wound is concealed, and there is no obvious scar even with careful repair to achieve the mini effect.
4 Major experience
Whether MLC can be carried out successfully or not, instrumentation is the main factor, followed by technique.
Instrument selection In the last decade or so, we have selected imported instruments with diameters of 1.7mm, 2mm, 3mm and domestic 2.8mm and 3mm miniature and imported 1.7mm, 3mm, 4mm and 5mm miniature laparoscopes for clinical application studies, and we found that 1.7mm instruments are too thin and soft to firmly grip the gallbladder, making surgery difficult. Domestic miniature laparoscopic instruments are cheap, but the selected materials are not strong enough and are easily lost, making them more costly. Now mainly imported 2mm (American Surgical Company) instruments are used, and hook electrodes and other knot pushers do not exceed 3mm.
The instruments used in MLC are delicate, and it is difficult to grasp the exposure and easy to stab the abdominal organs, so it requires skillful routine LC foundation and careful intraoperative operation to ensure the success of the operation and the safety of the patient.
The scope of MLC is smaller than that of LC, and those who do not meet the indications should not use it reluctantly, otherwise it may bring more losses to the patient.
When the specimen is removed, a special gallbladder bag with thread is used, which is non-polluting to the wound and does not need to change the mirror, and the results are better.
At present, there are more MLC methods, and the operator chooses according to his situation. As long as the procedure is safe and effective, fast and convenient, and the patient’s wound is subtle and the scar is not obvious, the purpose is achieved. The two-hole method may not be more effective than the four-hole method if both miniature instruments are used.
5 Application Prospects
MLC further minimizes the invasiveness of traditional LC, and the mini-laparoscopic technique is generally welcomed by patients because of the more aesthetic results, less intraoperative bleeding, less postoperative pain, and shorter hospital stay and recovery period compared with the traditional (or common) laparoscopic technique. However, the imported instruments used in this technique are expensive, and the domestically produced micro-instruments have not yet met the requirements and have not been replaced, resulting in higher MLC charges than ordinary LC. In addition, because the instruments are small and sharp with limited gripping force, the gallbladder is not firmly grasped, and the clamping cannot be applied during surgery, so the technical requirements of the surgeon are slightly higher. The above factors have a certain impact on the promotion and popularity of MLC technology. However, with the improvement of people’s life in China, people’s demand for surgery is getting higher and higher. With the progress of science and technology, the introduction of new materials and advanced equipment, and the improvement of mini-instruments, we firmly believe that MLC has a better future of application. The most delightful thing is that in recent years, the surgery of preserving gallbladder has been paid more and more attention, and mini-laparoscopic technology has been applied to preserving gallbladder surgery. Mini-laparoscopic cholecystectomy is further minimally invasive than MLC, curing gallbladder disease and preserving gallbladder is truly minimally invasive.
Surgical incision after mini-laparoscopic cholecystectomy
Surgical incision after mini-laparoscopic cholecystectomy
(This article has been published in Journal of Laparoscopic Surgery,2009,14(1):8-9)